Who Is Dangerous and Who Is Not?

In light of the shooting that occurred this week, Dr. Seifert offers her insights on the connection between mental illness and violence.

Not all mentally ill people are violent and not all violent people are mentally ill. Mental illness and violence are separate concepts. Assessments and interventions for these are different also. However, there is some overlap. Systems that address procedures for managing violence in others need to improve on identifying violence and taking appropriate precautions.

There have been 21 U.S. incidents of mass murder since 2000 (Larry Cohen, Huffington Post). Not all of the alleged shooters of the last decade have been tried and convicted. While everyone is innocent until proven guilty, we still need to find answers to preventing the increasing number of mass murders in the last decade.

Is being mentally ill a risk factor for violence? A MacArthur study found that hospitalized severely mentally ill people were less likely to be violent than those in the general community. Additionally, the study found that being dually diagnosed with a mental illness and a substance abuse disorder placed a person at greater risk for violence. A NIMH epidemiological study found that people with mental illness (16% lifetime prevalence) are slightly more likely to be violent than the average person in the community without a mental illness (7% lifetime prevalence). However, those with both severe mental illness and substance abuse disorders were 7 times more likely to be violent than those without either disorder.

From my research, I would add several more suggested risk factors for young adult mass murder. I propose that the more risk factors a person has, the more likely the person is to become violent toward others. Knowing the risk factors for young adult mass murder, in particular, can help professionals provide effective treatment for those that come to their attention before there is a tragic act. The risk factors include: belief in aggression as a means to an end, problems at school or at work, difficulty getting along with others, anger management problems, violent communications, and major life stressors which injure self-esteem.

A dialogue is needed about 1) how to determine whether someone is dangerous to himself or others 2) what can be done when professionals or family members have concerns about a person's dangerousness to others 3) whether danger must be imminent in order to have someone committed to a forensic hospital for a thorough evaluation and treatment 4) whether personal rights to freedom are more important than public safety and where the line is between them.

The pendulum has swung from keeping people in hospitals for the mentally ill too long, to making it almost impossible for someone to be committed to a hospital to determine if he is going to harm himself or others. While most mentally ill people are not dangerous, some are. Some individuals do sometimes stop taking their medications and become dangerous. That problem has to be fixed while protecting individual rights. A balance must be found.

A second problem is that the accuracy of clinical judgment for predicting future risk of dangerousness is little better than chance, but mental health professionals in the U.S. continue to use clinical judgment to determine if someone is dangerous. There are valid and reliable tools to increase the accuracy of the determination of dangerousness and appropriate treatment plans, but they are not widely used in the US. A new conversation around this issue is needed.

A third issue is the continued discharge of patients from psychiatric hospitals for severely and chronically mentally ill persons (since 1968), and insufficient funding to care for these people in the community mental health centers. It is hoped that the Affordable Care Act, with better integration of physical and mental health care, will reduce the overall cost of health care and improve the provision of mental health services. More readily available and higher quality mental health and substance abuse services could help prevent future violence.

What do you think about the connection between mental illness and violence?